Surgical options for patients with osteoarthritis of the knee

Transcription

1 Surgicl options for ptients with osteorthritis of the knee Jörg Lützner, Philip Ksten, Klus-Peter Günther nd Stephn Kirschner strct Osteorthritis (OA) of the knee is progressive disese tht ultimtely dmges the entire joint. Knee OA should initilly e treted conservtively, ut surgery should e considered if symptoms persist. surgicl tretments for knee OA include rthroscopy, osteotomy nd knee rthroplsty; determining which of these procedures is most pproprite will depend on severl fctors, including the loction nd severity of OA dmge, ptient chrcteristics nd risk fctors. Arthroscopic lvge nd deridement do not lter disese progression, nd should not e used s routine tretment for the osteorthritic knee. Bone mrrow stimultion techniques such s microfrcture re primrily used to tret focl chondrl defects; the evidence for the use of these techniques for knee OA remins uncler. The gol of osteotomy for unicomprtmentl knee OA is to trnsfer the weight lod from the dmged comprtment to undmged res, delying the need for joint replcement. This procedure should e considered in young nd ctive ptients who re not suitle cndidtes for knee rthroplsty. For ptients with severe OA, totl knee rthroplsty cn e sfe, rewrding nd cost-effective tretment. in selected ptients with isolted medil or ptellofemorl OA, unicomprtmentl knee rthroplsty nd ptellofemorl replcement, respectively, cn e successful. Lützner, J. et l. Nt. Rev. Rheumtol. 5, (2009); doi: /nrrheum Introduction osteorthritis (o) of the knee (Figure 1) is progressive disese tht ultimtely dmges the entire joint. Knee o is common disese tht hs n incresed incidence nd prevlence in people over the ge of 40 yers; round 10% of ll people older thn 60 yers of ge hve rdiologicl signs of knee o, nd out hlf of those complin of clinicl symptoms. 1 musculoskeletl diseses, nd especilly o, re common cuses of disility nd limittions to ctivities of dily living nd work. the direct cost of o in the us is estimted t $81 illion per yer, with further $47 illion in indirect costs, including lost wges nd productivity. 1 5 initil tretment of knee o is conservtive, nd includes eductionl informtion, physicl therpy, regulr exercise, weight reduction, the use of cetminophen (prcetmol) nd/or nsids nd intr-rticulr injections of corticosteroids or hyluronte. 6,7 if symptoms persist fter the ppro prite use of non surgicl tretment, however, surgery cn e recommended. 6 this review outlines the surgicl procedures ville to tret knee o t vrious stges nd in considertion of ptientrelted fctors, such s ge, level of physicl ctivity nd risk fctors. Competing interests J. Lützner declres ssocitions with the following compnies: Aesculp, stryker. P. Ksten declres ssocitions with the following compnies: Biosfe, Tornier. K-P. Günther declres ssocitions with the following compnies: stryker, Zimmer. s. Kirschner declres ssocitions with the following compnies: Aesculp, stryker, Zimmer. see the rticle online for full detils of the reltionships. Arthroscopic surgery rthroscopy is widely used in the tretment of o, despite the lck of evidence showing it to hve greter enefit thn other tretments. 8,9 the different rthroscopic techniques include lvge, deridement, one mrrow stimultion of contined chondrl lesions, osteochondrl trnsplnttion, nd utologous chondro cyte trnsplnttion. s utologous osteochondrl 10 nd chondrocyte trnsplnttion 11,12 re not indicted for knee o, we will not discuss them in this review. most pulished studies of rthroscopic procedures for knee o (tle 1) re of limited qulity, owing to lck of rndomiztion, lck of control group, short-term follow-up, or inconsistent ssessment methods. 13 only three rn domized trils hve compred rthroscopic surgery with nonsurgicl control procedure for knee o. 8,9,14 lvge nd deridement the rtionle for rthroscopic lvge is to wsh out deris nd inflmmtory enzymes, consequently reducing symptoms of synovitis nd pin nd improving function. rden et l. 14 compred improvements in womc score following tidl irrigtion, performed with 3.2 mm wrist rthroscope, nd intr-rticulr corticosteroid injection. Both tretments provided short-term pin relief; however, the enefits lsted longer fter irrigtion. fter 6 months, only 29% of ptients who received corticosteroids reported continued improvement, compred with 64% of those who underwent tidl irrigtion. in oth groups, the est outcomes were reported in ptients with effusion nd rdiogrphic signs of mild o t seline. vn oosterhout et l. 15 compred rthroscopic lvge in Deprtment of Orthopedic surgery, University Hospitl Crl Gustv Crus, Technicl University of Dresden, Germny (J. lützner, P. Ksten, K.-P. günther, S. Kirschner). Correspondence: K.-P. Günther, Deprtment of Orthopedic surgery, University Hospitl Crl Gustv Crus, Medicl Fculty of the Technicl University of Dresden, Fetscherstrsse 74, D Dresden, Germny klus-peter.guenther@ uniklinikum-dresden.de nture reviews rheumtology volume 5 June

2 Key points Osteorthritis (OA) of the knee should first e treted nonsurgiclly; however, if this pproch fils, severl surgicl options re ville Arthroscopic lvge nd deridement should not e used s routine tretment in knee OA, s only selected ptients might enefit; neither procedure lters disese progression evidence for the use of one mrrow stimultion techniques for knee OA is uncler; the primry indiction for this procedure remins focl crtilge defects Osteotomy is recommended for young, ctive ptients with knee OA who re not suitle cndidtes for rthroplsty Totl knee rthroplsty is sfe nd cost-effective tretment for severe knee OA, lthough the reltive risks nd enefits should e thoroughly considered Unicomprtmentl knee rthroplsty or ptellofemorl replcement cn e n option for selected ptients with isolted medil or ptellofemorl OA, respectively Figure 1 Chrcteristic ppernce of dvnced osteorthritis of the knee, occurring minly in the medil comprtment. rdiogrph reveling medil joint spce nrrowing nd the presence of osteophytes. Arthroscopic view shows crtilge loss t the medil femorl condyle nd tii. comintion with corticosteroids, rthroscopic lvge lone, nd joint spirtion in comintion with corticosteroids. the results demonstrted superior outcomes following rthroscopic lvge comined with dministrtion of corticosteroids. only ptients with inflmmtory rthritis were included, nd no vlidted outcome mesure ment scores were used; therefore, the results of this study re not directly pplicle to knee o. rthroscopic deridement includes not only lvge nd wshout of deris, ut lso the immedite tretment of other mechnicl prolems (tht is, removl of loose odies, hypertrophied synovium nd torn meniscl frgments); mny surgeons lso shve firillted rticulr crtilge nd remove detched crtilge flps. these procedures re thought to provide enefit eyond tht of lvge y improving the mechnicl conditions of the knee joint. in prospective rndomized tril, however, moseley et l. 8 did not find ny significnt difference in pin relief over 24 months following rthroscopic deridement or plceo procedure. the results of this study hve een extensively deted, s severl methodologicl issues were rised ginst the protocol employed, including the use of n unvlidted outcome mesurement (nmely the Knee-specific Pin scle ), restrictive ptient selection (fvoring minly mle ptients) nd possile selection is (44% of eligile ptients declined to prticipte, nd there ws no strtifiction for o severity). most of these issues were ddressed in study y Kirkley et l. 9 tht compred comintion of rthroscopic lvge nd/or deridement nd physicl nd medicl therpy with physi cl nd medicl therpy lone. gin, no differences were oserved etween the two tretment groups in womc score wellvlidted outcome mesure fter 2 yers. recent Cochrne review 16 of rthroscopic deridement for knee o identified only three well-performed studies, 8,17,18 nd concluded from these tht the procedure hs no enefit for o rising from mechnicl or inflmmtory cuses. However, criticl systemtic review of ll ville pulictions 13 concluded tht rthroscopic deride ment offered enefit to ptients with meniscl ters nd knees with low-grde o. the osteorthritis reserch society interntionl (orsi) views rthroscopic deridement for knee o s controversil. 7 on the sis of ville evidence, rthroscopic lvge seems to provide only short-term enefit to selected ptients with mild rdiogrphic o nd effusion. in ddition, rthroscopic deridement should not e used s routine tretment for o of the knee, lthough ptients with symptomtic meniscl ters nd loose odies with locking symptoms could enefit. neither procedure lters the progression of o. Bone mrrow stimultion the im of one mrrow stimultion techniques is to induce leeding from the suchondrl one followed y the formtion of firin clot, the migrtion of undifferentited mesenchyml stem cells nd, consequently, the formtion of firocrtilginous tissue tht covers fullthickness chondrl lesions. these techniques were developed minly for the tretment of focl chondrl defects, ut re lso used in osteorthritic knees. Different techniques for penetrting suchondrl one include drilling, 19 microfrcturing, 20 nd rsion rthroplsty. 21 microfrcturing is used more often thn drilling or rsion ecuse it is esy to perform nd voids het dmge. the microfrcture technique 20 involves deridement of ll unstle crtilge to one level to form stle rim of helthy crtilge round the defect; specilly designed wls re then used to mke multiple holes 2 4 mm deep nd 3 4 mm prt (Figure 2). rehilittion includes continuous pssive motion nd prtil weight ering for 6 8 weeks, lthough this estimte of heling time is sed on scnt clinicl dt. in nonhumn primte model of microfrcture, the repir tissue ws still immture fter 6 weeks; 22 therefore, longer period of prtil weight ering could e necessry. 310 JUNE 2009 volume 5

3 whtever technique is used, the firocrtilginous tissue produced y one mrrow stimultion does not hve the iomechnicl properties nd durility of the originl rticulr crtilge, nd the tretment proly does not lter the progression of o. Bone mrrow stimu ltion is not, therefore, curtive tretment; however, mny ptients otin relief from symptoms for severl yers. 23 the results re good for smll nd focl chondrl lesions, which occur in ptients with moderte o; in dvnced o, which is usully ssocited with lrge chondrl defects, the techniques re less effective. unfortuntely, no rndomized or controlled prospective studies hve ppropritely evluted these techniques. Clinicl trils hve often used distinct indictions nd techniques, nd only short-term follow-up. in summry, the evidence for the use of one mrrow stimultion techniques in ptients with knee o remins uncler. the primry indiction for this surgicl procedure remins focl crtilge defects. Osteotomy osteotomy is n estlished procedure for the tretment of unicomprtmentl knee o tht hs een in use since the 1960s. 24,25 osteotomy entils cutting through the one nd fixing it in nother position in order to chnge the lignment nd, consequently, redistriute the weight lod. s result of technicl dvnces in uni comprtmentl nd totl knee rthroplsty, osteotomy hs ecome less frequently performed. with the introduction of new techniques nd more-stle fixtion devices, however, this procedure is experiencing resurgence in some countries. in unicomprtmentl knee o, the gol of osteotomy is to trnsfer the weight lod from dmged res to the unimpired femorotiil comprtment, nd consequently reduce symptoms nd dely the need for joint replcement. medil comprtment o is most often ssocited with vrus deformity of the tii; therefore, high tiil osteotomy is the technique most often performed round the knee. o of the lterl comprtment in comintion with vlgus mllignment of the distl femur is treted with suprcondylr femorl osteotomy. dditionl rthroscopic tretment is often performed t the sme time s osteotomy, mking it difficult to distinguish the effect of ech opertion. erly results from osteotomy re usully good, with deteriortion over time owing to o progression. the proility of osteotomy survivl (defined s nonconversion to totl knee rthroplsty) fter 10 yers rnges from 50% to 90% met-nlysis 31 of high tiil osteotomy demonstrted n overll 10-yer filure rte of 25%, nd n verge of 72 months etween high tiil osteotomy nd conversion to totl knee rthroplsty. the proility of good or excellent result ws 75% fter 60 months nd 60% fter 100 months. 31 severl studies hve demonstrted tht the degree of correction is the most importnt fctor for the success of osteotomy. 28,32 Computer-ssisted nvigtion improves the precision of correction, nd possily improves the Tle 1 Quntity of literture relting to vrious surgicl procedures for knee OA Serch terms used Osteorthritis nd lvge 181 Osteorthritis nd deridement 365 Osteorthritis nd osteotomy nd knee 874 Osteorthritis nd unicomprtmentl nd knee 407 Osteorthritis nd ptellofemorl nd knee 490 Osteorthritis nd (rthroplsty or replcement) nd knee 3,300 outcome risk fctors for osteotomy filure include femle sex, oesity nd severe o. 27,28 two sic high tiil osteotomy techniques re used to tret vrus deformity of the tii: lterl closing wedge nd medil opening wedge osteotomy (Figure 3). lterl closing wedge osteotomy generlly requires fiulr osteotomy, which incurs the risk of peronel nerve plsy; dditionl disdvntges include the need for two sw cuts nd detchment of the extensor muscles. on the other hnd, lrge re of one contct is produced, which supports relile postsurgicl one heling. medil opening wedge osteotomy hs ecome incresingly populr since the development of ngle-stle implnts, owing to the simple medil pproch involved nd the possiility of precisely djusting the degree of correction. Bone heling following n opening wedge procedure is reportedly relile, even if the osteotomy gp is not treted y one grfting. 36 to dte, there is no evidence for etter outcome following either the opening or closing wedge technique. 37 Given tht unicomprtmentl nd totl knee rthroplsty re not idel for ptients who re young, ctive nd hve physiclly demnding jos, osteotomy should e considered in these cses. the idel cndidte for osteotomy is ctive, younger thn 50 yers old, hs history of isolted medil comprtment pin, ml lignment of less thn 15, metphysel tiil vrus, full rnge Numer of rticles retrieved Numer of rticles retrieved from serch of the PuMed dtse conducted in Decemer Figure 2 Microfrcture is one mrrow stimultion technique tht cretes smll holes in the one with the im of stimulting growth of firocrtilginous tissue. To induce leeding in chondrl defect t the medil femorl condyle, holes re mde 3 4 mm prt. A defect of the medil femorl condyle is filled with newly generted firocrtilginous tissue. nture reviews rheumtology volume 5 June

4 Figure 3 High tiil osteotomy, often used to tret medil unicomprtmentl knee osteorthritis. Osteotomy is crried out t the proximl end of the tii to overcorrect vrus mllignment nd trnsfer the weight lod to the intct lterl comprtment. The closing wedge technique involves the excision of lterlsed one wedge from the proximl tii nd prt of the fiul. The opening wedge technique requires only one osteotomy nd the medil-sed opening of the resulting gp. Figure 4 Totl knee rthroplsty replces the femorl nd tiil contct res. Additionl ptellr replcement cn e done optionlly. Anteroposterior nd lterl views show the metl femorl nd tiil prosthetic implnts. A fixed polyethylene insert is plced etween the two implnts. of motion of the knee, Bmi of less thn 30 nd rdiogrphic evidence of moderte, isolted medil comprtment o. 38 However, the enefits of osteotomy re less immedite thn those of knee rthroplsty, nd the outcome is less predictle. Joint replcement replcement of the entire knee joint, or totl knee rthroplsty, is sfe nd cost-effective tretment for severe o of the knee (Figure 4). 39 Durle llevition of pin nd improvement of physicl function cn e expected following the procedure. 39,40 in ddition to physicin-derived dt, ptient-centered outcome mesurements hve lso ecome n essentil component of ny long-term nlysis of the success of totl knee replcement. 41 owing to its irreversile nture, joint replcement is recom mended only in ptients for whom other tretment modlities hve filed. 6 the procedure hs remrkly higher risk of filure 10 yers fter implnttion in ptients ged 50 yers nd younger 43 thn in ptients ged 70 yers or older. 39,42,43 Complictions of joint replcement surgery include prosthetic loosening, wering of the poly ethylene insert, infection nd periprosthetic frctures. For ptients younger thn 50 yers, therefore, the risks nd enefits of less-invsive surgicl lterntives should e thoroughly weighed ginst those of totl knee rthroplsty. 40,44 Ptients over 70 yers of ge re considered the est cndi dtes for totl knee replcement. 39 incresingly, older ptients with severe o, s well s younger ptients, re successfully treted with totl knee rthroplsty. 39,45 registers from ll over the world, such s the swedish Knee rthroplsty register, 45 demon strte constnt increse in joint replcement rtes. Joint replcement must e considered in ptients with rdiogrphic evidence of knee o who hve pin nd disility refrctory to conservtive or joint-preserving therpy. 44 the indiction criteri for joint replcement surgery, however, might vry etween countries. 46 the demnd for musculoskeletl helth cre services is expected to increse sustntilly in ging popultions s pulic expecttions rise nd dignosis nd tretment improve. 47 using structured method to score pin, function, movement nd deformity, the new Zelnd priority criteri ensure n imprtil distriution of totl joint replcement. 48 in sweden, ptients re ctegorized into three groups on the sis of pin level, serious functionl impirment, nd t lest 50% reduction in rdiogrphiclly visile joint spce. 49 By contrst, the ontrio Hip nd Knee replcement Project tem suggests ptient-oriented pproch: the need for joint replcement surgery is indicted y oth the ptient s own perceptions of overll symptomtic urden nd physicin-derived informtion from clinicl judgments nd helth sttus instrument scores. 50 still, n evidence-sed consensus on the pproprite indiction for knee replcement needs to e developed. the idel timing of joint replcement surgery is controversil. Ptients with more-severe o gin more from the opertion, ut remin in worse helth post opertively, thn ptients with less-severe disese. 51 surgery t n erlier disese stge could, therefore, e preferle. ge nd comoridities re sustntil risk fctors for dverse outcomes fter joint replcement. the risks of mjor complictions, including mortlity, infection, nd 312 JUNE 2009 volume 5

5 pulmonry emolism, re well known. 52 in ddition to screening for these complictions, pre opertive ssessment of mentl sttus with stndrdized instruments, such s the mini mentl stte exm, cn help to identify older ptients t risk for delirium. 39 unicomprtmentl knee replcement unicomprtmentl knee rthroplsty could e indicted in cses where o involves only one of the three comprtments of the knee the medil tiiofemorl, lterl tiiofemorl or ptellofemorl comprtment. the most common unicomprtmentl knee rthroplsty replces the contct surfces of only the medil tiiofemorl comprtment with two metllic prosthetic devices nd inserts polyethylene inly etween them (Figure 5). For medil comprtment knee rthroplsty to e indicted, the knee ligments (nterior nd posterior crucite ligments, medil nd lterl collterl ligments) should e intct, the vrus deformity should e correctle, nd the lterl comprtment should hve full-thickness crtilge. 53 unicomprtmentl knee replcement should not e performed in knees tht hve previously undergone high tiil osteotomy. 54 the use of modern implnts nd surgicl techniques hs improved clinicl results nd survivl rtes of medil unicomprtmentl knee rthroplsty. 55 outcomes for the tretment of lterl unicomprtmentl knee o re rrely reported. 56 these results re less predictle thn those of medil unicomprtmentl o, despite recent improvements in implnt design. scientific dete out the involvement of the ptellofemorl joint in knee o is ongoing. the experience of the surgeon hs considerle impct on the outcome of unicomprtmentl rthroplsty: lerning curve, with worse results for the surgeon s first 10 procedures, hs een suggested. 57 long-term survivl depends on the rte of implnt filure nd/or progression of o in the lterl or ptellofemorl comprtment of the knee. in generl, the 10-yer survivl rte of medil unicomprtmentl knee replcement is slightly worse thn tht of totl knee rthroplsty. 45 specilized centers report equl survivl rtes for medil unicomprtmentl implnt nd estlished totl knee rthroplsty implnts. 58 in cses of conversion from medil unicomprtmentl knee replcement to totl knee replcement, one-third of ptients need one grfting or wedges to ugment the medil one defect of the tii. 59 the revision of unicomprtmentl knee rthroplsty, in which dmged implnts re replced, is considered esier, nd the results superior, to revision of totl knee replcement. 60 isolted ptellofemorl o occurs in 10% of ptients with knee o. 61 underlying disorders often include prior trum to the ptell, mllignment of the ptello femorl joint, trochle dysplsi nd degenertion secondry to deep ending, overuse nd/or ge. 62 Few ptients undergo isolted ptellofemorl replcement, 63,64 lthough this numer is incresing. specilized centers report encourging results. 63 on the other hnd, these ptients cn lso e treted with conventionl totl knee replcement, with Figure 5 Unicomprtmentl knee rthroplsty in isolted medil osteorthritis replces only the medil femorl nd tiil contct res. Anteroposterior nd lterl views show the metl femorl nd tiil prosthetics. A moile polyethylene meniscl insert is plced etween the two implnts. relile nd fvorle results one reson for filure of isolted ptellofemorl rthroplsty is the progression of o in the tiiofemorl joint. indictions for isolted ptello femorl replcement include diseses of the ptellofemorl joint leding to isolted rthritis: trochler dysplsi, post-trumtic rthritis nd recurrent dis loctions or suluxtions. 68 o of the tiiofemorl joint should e ruled out, s the tretment would e unsuitle for such cses. 62 if the suitility of ptellofemorl replcement is uncertin, conventionl totl knee replcement is recommended. replcement of the ptellofemorl joint is likely to hve sustntil lerning curve for the surgeon, nd is est performed in specilized centers. 40 totl knee replcement totl knee replcement is the gold stndrd for end-stge knee o. 39 lrge numer of well-designed studies hve reported preopertive nd postopertive results nd precisely descried study popultions; these dt were pooled for us government-commissioned helth technology ssessment of totl knee replcement. 69 most of the ptients in the report were out 75 yers of ge, two thirds were femle nd one third were considered oese; 90% suffered from o. instruments used to report improvements included the Knee society Knee score (KsKs), the Hospitl for specil surgery (Hss) Knee score, the womc score nd the sf-36, generl-purpose 36- question helth survey. expressed s men effect sizes, with result greter thn 0.8 considered lrge tretment effect, increses in these scores vried with the scoring instrument used. with the Hss score, the oserved men effect size rnged from 3.91 (2-yer follow-up) to 2.97 (>5 yers follow-up). studies using the KsKs reported effect sizes etween 2.35 nture reviews rheumtology volume 5 June

6 (0 2 yers) nd 2.67 (>5 yers). in womc studies with 2-yer follow-up, the men effect size ws 1.62, nd, finlly, the men effect size using the sf-36 ws the procedure, then, ws generlly reported to produce sustntil improvements, lthough the use of more-joint-specific outcome mesures ws ssocited with the reporting of remrkly greter effects. in this report, pooling ll the included studies resulted in cumultive rte of dverse events of 5.4%. the most severe compliction ws periopertive mortlity (0.5%). 39 of note, 0.71% of infections nd 0.41% of pulmonry emolism occurred within the first 90 dys fter surgery. 52 the swedish Knee rthroplsty registry 45 shows tht revision rtes of totl knee rthroplsty hve decresed over time. improved surgicl techniques nd improved implnt technology were oth suggested s resons for the improved outcomes. the rte of complictions in some studies re inversely relted to hospitl nd surgeon volumes of opertions per yer. 39 comprison of outcomes following either the retention or scrifice of the posterior crucite ligment (PCl) during totl knee replcement is provided in Cochrne report sed on eight rndomized studies; totl of 570 ptients with o or rheumtoid rthritis followed-up for 5 yers were included. 70 no differences in pin or strength were found etween ptients whose PCl ws scrificed nd those in whom it ws retined. Ptients whose PCl ws scrificed nd in whom posterior stilized inly ws used showed n 8 greter increse in rnge of motion compred with those whose PCl ws retined. the clinicl scores (using the Hss score) demonstrted sttisticlly significnt dvntge of intropertive PCl scrifice over retention, lthough the clinicl relevnce of this dvntge is questionle. seprte Cochrne report compred the clinicl outcomes nd post opertive rnge of motion following the use of either moile or fixed tiil inserts in totl knee rthroplsty: only two studies met the inclusion criteri, nd the outcomes did not differ etween the two tretment modlities. 71 two new technologies introduced into totl knee rthroplsty surgery re minimlly invsive surgery (mis) nd nvigted totl knee rthroplsty. gret numer of reports del with minimlly invsive 39 totl knee rthroplsty lthough no ccepted definition of mis exists. in contrst to the numerous ville descriptions of mis techniques, only few rndomized controlled trils hve investigted the potentil ene fits of mis. some trils show eneficil short-term effect of mis, wheres others do not. met-nlysis of short-term outcomes showed smll dvntge for mis over conventionl surgery, ut minly in studies tht comined mis with the use of nvigtion system. 72 Computer nvigtion improves the precision of post opertive lignment following totl knee rthroplsty, s shown in long-leg rdiogrphs. 73 no dditionl effect of computer nvigtion hs een shown on component lignment or erly clinicl outcomes. whether this improved precision will led to etter long-term results nd lower revision rtes is unknown. Computer nvi gtion requires longer operting times thn conventionl surgery, nd hs reported lerning curve of out 30 procedures. 74 these fcts might hve influenced the mjority of surgeons who not do nvigte ech totl knee rthroplsty, even though the equipment is ville. 75 in summry, no cler evidence exists to recommend the widespred use of either mis or computer nvigtion in totl knee rthroplsty. Conclusions initilly, tretment of knee o should e non surgicl. if this therpy fils, however, surgicl tretment cn e recommended. 6,7 in dvnced stges of knee o with complete loss of rticulr crtilge, totl knee rthro plsty relily relieves pin nd improves function. if o is limited to the medil comprtment, unicomprtmentl knee rthroplsty is eqully effective s totl knee replcement. osteotomy should e considered for young, ctive ptients with unicomprtmentl o. Bone mrrow stimultion techniques cn e used to tret full-thickness chondrl lesions; ptients with moderte o with smll chon drl defects enefit most from this pproch. rthro scopic lvge nd deridement should not e used s routine tretments for knee o; however, ptients with symptomtic meniscl ters nd loose odies with locking symptoms might enefit from these procedures. in summry, ll ville surgicl tretments should e considered, nd the pproprite tretment selected on the sis of the ptient s chrcteristics, s well s the presenttion nd severity of the disese. Review criteri Articles pulished in english nd Germn were identified y serching PuMed in Decemer 2008 using the following serch terms: osteorthritis nd lvge, osteorthritis nd deridement, osteorthritis nd osteotomy nd knee, osteorthritis nd unicomprtmentl nd knee, osteorthritis nd ptellofemorl nd knee, nd osteorthritis nd (rthroplsty or replcement) nd knee. 1. Merx, H., Dreinhofer, K. e. & Gunther, K. P. socioeconomic relevnce of osteorthritis in Germny [Germn]. Z. Orthop. Unfll. 145, (2007). 2. Jckson, D. w., simon, T. M. & Aermn, H. M. symptomtic rticulr crtilge degenertion: the impct in the new millennium. Clin. Orthop. Relt. Res. 391 (Suppl.), s14 s25 (2001). 3. Buckwlter, J. A., sltzmn, C. & Brown, T. The impct of osteorthritis: implictions for reserch. Clin. Orthop. Relt. Res. 427 (Suppl.), s6 s15 (2004). 4. sturmer, T., Gunther, K. P. & Brenner, H. Oesity, overweight nd ptterns of osteorthritis: the Ulm Osteorthritis study. J. Clin. Epidemiol. 53, (2000). 5. smson, D. J. et l. Tretment of primry nd secondry osteorthritis of the knee. Evid. Rep. Technol. Assess. (Full Rep.) 157, (2007). 6. Jordn, K. M. et l. eular recommendtions 2003: n evidence sed pproch to the mngement of knee osteorthritis: report of Tsk Force of the stnding Committee for interntionl Clinicl studies including Therpeutic Trils (escisit). Ann. Rheum. Dis. 62, (2003). 314 JUNE 2009 volume 5

7 7. Zhng, w. et l. OArsi recommendtions for the mngement of hip nd knee osteorthritis, Prt ii: OArsi evidence-sed, expert consensus guidelines. Osteorthritis Crtilge 16, Moseley, J. B. et l. A controlled tril of rthroscopic surgery for osteorthritis of the knee. N. Engl. J. Med. 347, (2002). 9. Kirkley, A. et l. A rndomized tril of rthroscopic surgery for osteorthritis of the knee. N. Engl. J. Med. 359, Hngody, L. et l. Mosicplsty for the tretment of rticulr crtilge defects: ppliction in clinicl prctice. Orthopedics 21, (1998). 11. Britterg, M. et l. Tretment of deep crtilge defects in the knee with utologous chondrocyte trnsplnttion. N. Engl. J. Med. 331, (1994). 12. Behrens, P. et l. indictions nd implementtion of recommendtions of the working group Tissue regenertion nd Tissue sustitutes for utologous chondrocyte trnsplnttion (ACT) [Germn]. Z. Orthop. Ihre. Grenzge. 142, (2004). 13. siprsky, P., ryzewicz, M., Peterson, B. & Brtz, r. Arthroscopic tretment of osteorthritis of the knee: re there ny evidence-sed indictions? Clin. Orthop. Relt. Res. 455, (2007). 14. Arden, N. K. et l. A rndomised controlled tril of tidl irrigtion vs corticosteroid injection in knee osteorthritis: the Kivis study. Osteorthritis Crtilge 16, vn Oosterhout, M., sont, J. K., Bjem, i. M., Breedveld, F. C. & vn Lr, J. M. Comprison of efficcy of rthroscopic lvge plus dministrtion of corticosteroids, rthroscopic lvge plus dministrtion of plceo, nd joint spirtion plus dministrtion of corticosteroids in rthritis of the knee: A rndomized controlled tril. Arthritis Rheum. 55, (2006). 16. Lupttrksem, w., Lopioon, M., Lupttrksem, P. & sumnnont, C. Arthroscopic deridement for knee osteorthritis. Cochrne Dtse of Systemtic Reviews 2008, issue 1. Art. No.: CD doi: / cd pu Hurd, M. J. Articulr deridement versus wshout for degenertion of the medil femorl condyle. A five-yer study. J. Bone Joint Surg. Br. 78, (1996). 18. Chng, r. w. et l. A rndomized, controlled tril of rthroscopic surgery versus closed-needle joint lvge for ptients with osteorthritis of the knee. Arthritis Rheum. 36, (1993). 19. Pridie, K. H. A method of resurfcing osteorthritic knee joints. in: Proceedings nd reports of councils nd ssocitions: British Orthopedic Assocition spring Meeting J. Bone Joint Surg. Br. 41-B, (1959). 20. stedmn, J. r., rodkey, w. G. & rodrigo, J. J. Microfrcture: surgicl technique nd rehilittion to tret chondrl defects. Clin. Orthop. Relt. Res. 391 (Suppl.), s362 s369 (2001). 21. Johnson, L. L. Arthroscopic rsion rthroplsty historicl nd pthologic perspective: present sttus. Arthroscopy 2, (1986). 22. Gill, T. J., McCulloch, P. C., Glsson, s. s., Blnchet, T. & Morris, e. A. Chondrl defect repir fter the microfrcture procedure: nonhumn primte model. Am. J. Sports Med. 33, (2005). 23. Miller, B. s., stedmn, J. r., Briggs, K. K., rodrigo, J. J. & rodkey, w. G. Ptient stisfction nd outcome fter microfrcture of the degenertive knee. J. Knee Surg. 17, (2004). 24. Coventry, M. B. Osteotomy of the upper portion of the tii for degenertive rthritis of the knee. A preliminry report. J. Bone Joint Surg. Am. 47, (1965). 25. Jckson, J. P. & wugh, w. Tiil osteotomy for osteorthritis of the knee. J. Bone Joint Surg Br. 43-B, (1961). 26. Akizuki, s., shikw, A., Tkizw, T., Ymzki, i. & Horiuchi, H. The long-term outcome of high tiil osteotomy: ten- to 20-yer follow-up. J. Bone Joint Surg. Br. 90, vn rij, T., reijmn, M., Brouwer, r. w., Jkm, T. s. & verhr, J. N. survivl of closingwedge high tiil osteotomy: good outcome in men with low-grde osteorthritis fter yers. Act Orthop. 79, Coventry, M. B., ilstrup, D. M. & wllrichs, s. L. Proximl tiil osteotomy. A criticl long-term study of eighty-seven cses. J. Bone Joint Surg. Am. 75, (1993). 29. Nudie, D., Bourne, r. B., roreck, C. H. & Bourne, T. J. The instll Awrd. survivorship of the high tiil vlgus osteotomy. A 10- to -22-yer followup study. Clin. Orthop. Relt. Res. 367, (1999). 30. Gstöttner, M., Pedross, F., Lieensteiner, M. & Bch, C. Long-term outcome fter high tiil osteotomy. Arch. Orthop. Trum Surg. 128, virolinen, P. & Aro, H. T. High tiil osteotomy for the tretment of osteorthritis of the knee: review of the literture nd met-nlysis of follow-up studies. Arch. Orthop. Trum Surg. 124, (2004). 32. Fujisw, Y., Msuhr, K. & shiomi, s. The effect of high tiil osteotomy on osteorthritis of the knee. An rthroscopic study of 54 knee joints. Orthop. Clin. North Am. 10, (1979). 33. Kim, s. J. et l. Medil opening wedge high-tiil osteotomy using kinemtic nvigtion system versus conventionl method: 1-yer retrospective, comprtive study. Knee Surg. Sports Trumtol. Arthrosc. 17, (2009). 34. Goleski, P. et l. reliility of nvigted lower lim lignment in high tiil osteotomies. Am. J. Sports Med. 36, Murer, F. & wssmer, G. High tiil osteotomy: does nvigtion improve results? Orthopedics 29, (2006). 36. Loenhoffer, P., Agneskirchner, J. & Zoch, w. Open vlgus lignment osteotomy of the proximl tii with fixtion y medil plte fixtor [Germn]. Orthopde 33, (2004). 37. Brouwer, r. w. et l. Osteotomy for treting knee osteorthritis. Cochrne Dtse of Systemtic Reviews 2007, issue 3. Art. No.: CD doi: / cd pu3 (2007). 38. Brinkmn, J. M. et l. Osteotomies round the knee: ptient selection, stility of fixtion nd one heling in high tiil osteotomies. J. Bone Joint Surg. Br. 90, NiH Consensus Pnel. NiH Consensus sttement on totl knee replcement Decemer 8 10, J. Bone Joint Surg. Am. 86-, (2004). 40. richmond, J. C. surgery for osteorthritis of the knee. Rheum. Dis. Clin. North Am. 34, wright, r. J. et l. Ptient-reported outcome nd survivorship fter Kinemx totl knee rthroplsty. J. Bone Joint Surg. Am. 86-, (2004). 42. rnd, J. A., Trousdle, r. T., ilstrup, D. M. & Hrmsen, w. s. Fctors ffecting the durility of primry totl knee prostheses. J. Bone Joint Surg. Am. 85-, (2003). 43. Hofmnn, A. A., Heithoff, s. M. & Cmrgo, M. Cementless totl knee rthroplsty in ptients 50 yers or younger. Clin. Orthop. Relt. Res. 404, (2002). 44. Gunther, K. P. surgicl pproches for osteorthritis. Best Prct. Res. Clin. Rheumtol. 15, (2001). 45. The swedish Knee Arthroplsty register. Annul report english/online/uplodedfiles/110_ skar2007_engl1.2.pdf. 46. Merx, H. et l. interntionl vrition in hip replcement rtes. Ann. Rheum. Dis. 62, (2003). 47. iorio, r. et l. Orthopedic surgeon workforce nd volume ssessment for totl hip nd knee replcement in the United sttes: prepring for n epidemic. J. Bone Joint Surg. Am. 90, Hdorn, D. C. & Holmes, A. C. The New Zelnd priority criteri project. Prt 1: Overview. BMJ 314, (1997). 49. Birrell, F., Johnell, O. & silmn, A. Projecting the need for hip replcement over the next three decdes: influence of chnging demogrphy nd threshold for surgery. Ann. Rheum. Dis. 58, (1999). 50. Llewellyn-Thoms, H. A., Arshinoff, r., Bell, M., willims, J. i. & Nylor, C. D. in the queue for totl joint replcement: ptients perspectives on witing times. Ontrio Hip nd Knee replcement Project Tem. J. Evl. Clin. Prct. 4, (1998). 51. Kennedy, L. G., Newmn, J. H., Ackroyd, C. e. & Dieppe, P. A. when should we do knee replcements? Knee 10, (2003). 52. soohoo, N. F., Lieermn, J. r., Ko, C. Y. & Zingmond, D. s. Fctors predicting compliction rtes following totl knee replcement. J. Bone Joint Surg. Am. 88, (2006). 53. Murry, D. w. Unicomprtmentl knee replcement: now or never? Orthopedics 23, (2000). 54. rees, J. L. et l. Medil unicomprtmentl rthroplsty fter filed high tiil osteotomy. J. Bone Joint Surg. Br. 83, (2001). 55. Borus, T. & Thornhill, T. Unicomprtmentl knee rthroplsty. J. Am. Acd. Orthop. Surg. 16, sh, A. P. & scott, r. D. Lterl unicomprtmentl knee rthroplsty through medil pproch. study with n verge five-yer follow-up. J. Bone Joint Surg. Am. 89, (2007). 57. rees, J. L., Price, A. J., Berd, D. J., Dodd, C. A. & Murry, D. w. 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8 60. sldnh, K. A., Keys, G. w., svrd, U. C., white, s. H. & ro, C. revision of Oxford medil unicomprtmentl knee rthroplsty to totl knee rthroplsty results of multicentre study. Knee 14, (2007). 61. McAlindon, T. e., snow, s., Cooper, C. & Dieppe, P. A. rdiogrphic ptterns of osteorthritis of the knee joint in the community: the importnce of the ptellofemorl joint. Ann. Rheum. Dis. 51, (1992). 62. Grelsmer, r. P. & stein, D. A. Ptellofemorl rthritis. J. Bone Joint Surg. Am. 88, (2006). 63. Ackroyd, C. e., Newmn, J. H., evns, r., eldridge, J. D. & Joslin, C. C. The Avon ptellofemorl rthroplsty: five-yer survivorship nd functionl results. J. Bone Joint Surg. Br. 89, (2007). 64. Crtier, P., snouiller, J. L. & Khefch, A. Longterm results with the first ptellofemorl prosthesis. Clin. Orthop. Relt. Res. 436, (2005). 65. Lskin, r. s. & vn steijn, M. Totl knee replcement for ptients with ptellofemorl rthritis. Clin. Orthop. Relt. Res. 367, (1999). 66. Mont, M. A., Hs, s., Mullick, T. & Hungerford, D. s. Totl knee rthroplsty for ptellofemorl rthritis. J. Bone Joint Surg. Am. 84-, (2002). 67. Prvizi, J., sturt, M. J., Pgnno, M. w. & Hnssen, A. D. Totl knee rthroplsty in ptients with isolted ptellofemorl rthritis. Clin. Orthop. Relt. Res. 392, (2001). 68. Delnois, r. e. et l. results of totl knee replcement for isolted ptellofemorl rthritis: when not to perform ptellofemorl rthroplsty. Orthop. Clin. North Am. 39, Kne, r. L. et l. Totl knee replcement. Evid. Rep. Technol. Assess. (Summ.) 1 8 (2003). 70. Jcos, w. C., Clement, D. J. & wymeng, A. B. retention versus removl of the posterior crucite ligment in totl knee replcement: systemtic literture review within the Cochrne frmework. Act Orthop. 76, (2005). 71. Jcos, w., Anderson, P. G., vn Limeek, J. & wymeng, A. A. B. Moile ering vs fixed ering prostheses for totl knee rthroplsty for post-opertive functionl sttus in ptients with osteorthritis nd rheumtoid rthritis. Cochrne Dtse Of Systemtic Reviews 2001, issue 2. Art. No.: CD doi: / CD pu2 (2004). 72. vvken, P., Gruer, M. & Dorotk, r. Outcomes fter minimlly invsive totl knee replcement met-nlysis [Germn]. Z. Orthop. Unfll. 146, Buwens, K. et l. Nvigted totl knee replcement. A met-nlysis. J. Bone Joint Surg. Am. 89, (2007). 74. Jenny, J. Y., Miehlke, r. K. & Giure, A. Lerning curve in nvigted totl knee replcement. A multi-centre study compring experienced nd eginner centres. Knee 15, Friederich, N. & verdonk, r. The use of computer-ssisted orthopedic surgery for totl knee replcement in dily prctice: survey mong esska/sgo-sso memers. Knee Surg. Sports Trumtol. Arthrosc. 16, JUNE 2009 volume 5